In a year when the United States has been riddled with bad news, confusion, and even threats of fines and incarceration (1) surrounding the use of influenza vaccines, the last thing you may be interested in thinking about is instituting a comprehensive inpatient influenza vaccination initiative. Despite the chaos, it is important to remember that, on average, 36,000 (2) people die and 226,000 (3) people are hospitalized annually from influenza, or “the flu,” and its complications. Additionally, a significant proportion of patients hospitalized will have co-morbid illness or be old enough to be considered in the highest risk category for complications of flu (4). Hospitalists are poised to act centrally in improving vaccination rates given the intensity of their patient contact and their expertise in developing best-practices-based systems.
What follows is a step-wise plan to help you begin an inpatient influenza vaccination initiative at your institution. Clearly, elements of this plan will need to be modified based on institutional structure and preference.
1. Define the problem locally. It is important to identify if any inpatient vaccination systems are already in place for any other vaccination (e.g., pneumococcal vaccination for splenectomy patients; tetanus for trauma patients, etc). If such a system already exists, review its successes and see if any of them may be borrowed for the influenza plan. Also determine if influenza vaccines have ever (even in a random, sptty fashion) been given out on your institution’s inpatient service. Understanding this history will help you address the issues of the “culture” of the institution.
2. Talk with your administration about making influenza vaccination a quality goal. One of the barriers ahead may be the mindset that vaccinations should only live in the world of outpatient physicians. By obtaining “buyin” from administration (e.g., the Chief Medical Officer), you may have some additional resources made available to you, and you may also be able to leverage the weight of the administration in recruiting help for the program. Remember, the 2005 Disease-Specific Patient Safety Goals from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) state that it is important to “develop and implement a protocol for administration and documentation of the flu vaccine.” (5)
3. Identify key players and meet with them. This plan cannot be sustained successfully as a one-person show. Ideally, you should create an influenza vaccination committee that has representatives of all the inpatient services (medicine, family medicine, surgery, obstetrics and gynecology, and pediatrics), as well as nursing leadership, infection control, pharmacy, information technology (for computerized order entry systems), and quality assurance. In academic institutions, you might also consider including a house officer and/or medical student. The initial meeting should review your findings with #1 and #2 above, as well as assessing this committee’s concerns about implementing an inpatient vaccination scheme. You should plan to initiate committee activities at least two to three months in advance of the anticipated availability of the vaccine.
4. Create a culture of vaccination. Vaccines are often not on the radar screen of most inpatient physicians as they deal with the more acute reasons for hospitalization. It is therefore important to begin introducing a culture change, demonstrating the importance of vaccinations to your staff, and shifting the prevalent mindset towards active engagement with your vaccination program. Identifying foreseeable problems and developing action plans will assist this process. Some issues may include:
- Physician and nurse attitudes and education about influenza and the vaccine (e.g., dispelling flu shot rumors, educating staff on the low risk of re-vaccinating a patient already vaccinated previously this season, explaining the lack of requirements for written informed consent for flu vaccination, encouraging health care workers to get flu shots themselves (6), etc.)
- Reminder systems for physicians to reinforce the need to vaccinate (posters, screen savers, emails, buttons)
- Communication with primary care physicians about patients who have been vaccinated
- Patient misconceptions about the vaccine’s side effects
5. Set a goal. It may be helpful to assess your inpatient service’s demographics for the past few years to identify the approximate denominator of eligible candidates for the vaccine based on age and key diagnoses. However, if your institution does not already have a history of active influenza vaccination on the inpatient service, start with a humble goal. It is attractive to assume that every patient who qualifies will be vaccinated. It is just not so. Have your influenza committee pick an achievable goal for your first flu season and stretch it in subsequent seasons. To achieve the goal, make sure each clinical area has an identifiable “champion” who can gently remind clinicians about the importance of vaccination. The higher the profile of the local champion the better, assuming the champion has the time and can offer the effort required to do the periodic reminders. Also make sure your pharmacy tracking and distributions systems are prepared to handle the increase in requests for the vaccines. Of note, many patients who are candidates for flu shots are also candidates for pneumococcal vaccines and both may be given together. Consider adding the pneumococcal vaccine to your efforts in appropriate patients.
6. Develop an “Opt Out” system. The CDC’s Advisory Committee on Immunization Practices recommends developing standing orders for both influenza and pneumococcal vaccinations (7). In computerized order entry, this suggestion may lead to a pre-selected order-set being built into the discharge orders that requires the physician to actively opt-out of the order. Paper-based systems may include standing printed orders, again, which require a physician to decline the order specifically. Such opt out systems have been shown to improve rates of vaccination significantly (8). Opt-out programs, however, still require that the clinician ordering the vaccine discusses the vaccine with the patient before it is administered.
7. Roll it out with a bang. Make sure the commencement of your flu shot program gets some press. Announce it at departmental meetings, on system-wide emails, and in hospital publications. Remember, this program is a demonstrable way of improving your patients’ health and an excellent way for hospitalists to show their systems-oriented approaches. Begin your roll-out as early as recommended by the local Department of Public Health so that your patients, many of whom will be at very high risk for complications of the flu, get early vaccination.
8. Give frequent feedback. Obtain vaccine distribution and utilization data at least twice monthly during the first two or three months. This period corresponds to the most critical period of the program as it is when flu shots must be delivered to ensure their efficacy come December-February when flu season typically peaks (9). Some groups may find that a bit of healthy competition (e.g., between services or between nursing units) may offer that edge to keep people vaccinating. Nonetheless, it is critical to keep your clinical areas updated with their performance, with public appreciation being expressed for the top notable clinical areas and low performers receiving extra encouragement and assistance. After the first few months, monthly reports and feedback will suffice, with the program running through the end of March.
9. Remain aware of the local and national flu scene. With the vaccine production problems of the current flu season and with the panic about the high mortality rates of the Fujian strain that was not included in the vaccine last season, it is clear that the flu news scene can be volatile and controversial. It is important to remain up to date on the current facts and be able to dispel any misinformation that may circulate. The following resources may prove helpful:
- The CDC’s influenza home page: http://www.cdc.gov/flu/
- The WHO’s influenza site: http://www.who.int/csr/disease/influenza/en/
- The state Department of Public Health
10. Plan for next season. At the end of flu season, reconvene the influenza committee and debrief. It is important to keep a log of the successes and failures of the season’s flu vaccine initiative to permit growth in subsequent seasons.
The CDC’s program, Healthy People 2010, has set a goal for influenza and pneumococcal vaccination of appropriate non-institutionalized individuals of 90% (10). This goal is achievable if all available resources for reaching out to such patients are utilized. The Massachusetts Hospital Association reports:
“Inpatient hospital stays are among the many missed opportunities for flu and pneumonia vaccination across health care settings. Up to 46% of subsequent influenza-related hospitalizations and 2/3 of influenza-related deaths occur among the elderly who have been previously hospitalized during the flu season. Up to 2/3 of patients hospitalized with serious pneumococcal infections have been hospitalized at least once within the previous 3-5 years (8).”
Hospitalists must take advantage of the opportunity that hospitalization affords our patients to receive the vaccines they need to stay healthy. Appropriate vaccine delivery is no longer solely the purview of the primary care physician – hospitalists must share this goal as well.
- The Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Public Health. Revised order to establish rules and priorities for the distribution and use of influenza vaccine. Available at: http://www.mass.gov/dph/cdc/epii/flu/flu_order.htm. Accessed November 3, 2004.
- Thompson WW, Shay DK, Weintraub E, et al. Mortality associated with influenza and respiratory syncytial virus in the United States. JAMA.2003;289:179-86.
- Thompson WW, Shay DK, Weintraub E, et al. Influenza-associated hospitalizations in the United States. JAMA. 2004;292:1333-40.
- CDC. Interim Influenza Vaccination Recommendations – 2004-2005 Season. Available at: http://www.cdc.gov/flu/protect/whoshouldget.htm. Accessed November 3, 2004.
- JCAHO. 2005 Disease-specific care national patient safety goals. Available at: http://www.jcaho.org/accredited+organizations/patient+safety/05+npsg/05_npsg_dsc.htm. Accessed November 3, 2004.
- Martinello RA, Jones L, Topal JE. Correlation between healthcare workers’ knowledge of influenza vaccine and vaccine receipt. Infect Control Hosp Epidemiol. 2003.Nov;24(11):799-800.
- CDC. Prevention and Control of Influenza Recommendations of the Advisory Committee on Immunization Practices (ACIP). Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/ rr5306a1.htm. Accessed November 8, 2004.
- Massachusetts Hospital Association. Opt-Out Standing Orders for Pneumonia and Influenza Vaccination for Hospital Inpatients: Best Practice Adoption Proposal to Improve Massachusetts Hospital Performance and Public Health. Available at: http://www.masspro.org/publications/pubs/misc/PNEUMHA2.pdf.
- CDC. Influenza: the disease. Available at: http://www.cdc.gov/flu/about/disease.htm. Accessed November 8, 2004.
- CDC. Healthy People 2010. Immunization and Infectious Diseases. Section 14-29a. Available at: http://www.healthypeople.gov/document/html/volume1/14immunization.htm. Accessed November 8, 2004.